Nursing staff uncomfortable with changes

[LT_Oneal_PAC]

So, I’ve been at my CAH EM/Hospitalist job for over a month now. In that time, I’ve had the nurses send 4 emails about “concerns” and last night they called my admin supervisor who texted my back up physician. Not a single bad outcome or “near miss,” they are just freaking out when I do typical EM things. They sent an email about me using push dose pressors and upset that I pushed the drug, not them (I did because they had never done it or knew how to mix it up). Sent another email because I used pain dose ketamine (0.1mg/kg). To be fair I did not realize they didn’t have a policy for this and I have since written a policy for them. Last night they were all pissy because I used an US to reassure a patient didn’t have a DVT with very low suspicion, that I did US guided IVs, and used it emergently to rule out pneumothorax. They question everything damn thing I do. My CP this morning chatted with me and agreed they are questioning to an inappropriate level. I would address their concerns, but they don’t come to me with questions. Instead go over my head immediately. My CP thinks the solution is to call the back up to talk about the things I’m doing and alleviate the fears of nursing that the docs have blessed my actions, which I think is dumb since I’m not there to treat patients and not nurses anxiety, and frankly a waste of my time. I was an ICU nurse for 4 years, and I don’t get their concerns because there is no evidence of deviation from the standard of care. No data for an incident report either. It reminds of when I started as a nurse and people just didn’t like doing things other than how they were always done. A nurse gave me a dirty look today because I said I wouldn’t be a middle man between the sheriff office and the ME. Sheriff office calls me, I’m supposed to call ME that office knows the number for, and then the ME calls sheriff office. I add nothing to the interaction other than a glorified switchboard operator. Honestly, I’m thinking about leaving since the FM docs aren’t really crazy about doing US for anything other than FAST, and they aren’t super jazzed about learning that. I presented them with everything they needed to build up an US program and bill for it, but they took it off the med staff agenda saying it wasn’t approved by the CEO to be added.

for reference, apparently up until a year ago only providers could push fentanyl.

maybe this is just venting. Anyone have a similar situation. 

[MediMike]

I had a complaint filed after cranking Vaso up to 0.06 in a crashing pHTN guy to spare norepi. Pharmacist straight said to the nurse that it induced cardiac arrest at that dose.

So yeah, I've run into some barriers and the ED seems more set in their ways from a nursing standpoint. To be honest, I get more pushback from ED RNs about things than I do the ICU nurses.

What you're dealing with though sounds pretty over the damn top. My advice, if you want to make it work, step up as a leader in the department and "treat" their anxiety. Offer a sit down with the nursing leadership, offer a weekly chalk talk on some of the things you've pissed them off about.

With that being said though, sounds like it's an organizational issue as well. FP docs are distancing themselves as well. Got to be frustrating man, I'm sorry.

[thinkertdm]

So, if I’m reading this right, your cp didn’t go to them and ask why they are reluctant to follow a legal order from a provider who is licensed and certified to do this, he came to you to ask wtf you are doing.  
Do they question an MDs orders? Are they coming down on you because of a misunderstanding of the limits of your training?  Why is the administration talking to you and not the nurses?  
I would suggest trying to work things out with the nurses, then writing up/reporting any nurse operating outside of their license.

However, with no backing from your colleagues and letting the nurses think they run the show, not going to be a good place for someone with your training and background.

Maybe I read it wrong.

[LT_Oneal_PAC]

She came to me because she got a message from the DON in the middle of the night, which did not contain the whole story.

No one is not following my order, necessarily. They just ask very condescendingly “are you sure?” To which I respond “do you have a alternative recommendation or issue?” Which they never do other than “we don’t normally do this” or, more commonly, didn’t look at the entire order for directions. What they are really doing is saying nothing then are just going email happy to the DON.

they absolutely would not do this to the docs. They treat them with deity reverence.

I offered to talk with the nurses and present the data, which the physician and PA said “data goes over there head. They are doers, not thinkers” Normally something I would push back on as most nurses (and myself as a nurse) love to know the whys, but I’m getting the sense they really don’t care about EBM or best practices, just keeping things status quo. They really are just doers. They wouldn’t accept a KVO order of 1-30cc/hr infusion. They needed a specific number. I had a mind to tell them 22.8 and that when I came back in 10 hours if anything other than 228cc volume had been infused, I would be writing an incident report. Obviously I just acquiesced.

Well, when I came in today, the senior PA here (no such title but he’s treated as such since he’s been here the longest) sounded like he laid some smack down saying  no one is going to tolerate anymore more of this junior high BS. He also had a talk with one of the docs and all agreed the DON is sticking her nose where it doesn’t belong. He has been very supportive and has been very happy to have me here. If I leave, I’ll feel most guilty about abandoning him. He said he wouldn’t blame me if I left, but would hate to hire someone with less experience.

after speaking more, apparently this isn’t the first time it’s happened. The senior said there was an assistant DON that tried to run him out of the facility 9 years ago when he first started.

I just finished a sick case. When I asked a nurse to hold on giving the fentanyl while I check the opposite arm BP as I had concern for dissection, she audibly huffed. WTF? Getting tired of this nonsense, she said she just does that when she is getting her bearings. Bull crap. You huffed and rolled your eyes. Now they are pissing on my shoulder and telling me it’s raining.

I appreciate the stage for venting. Feels much better.

[thinkertdm]

Makes more sense, and it looks like you do have support of the medical side.  
Best feeling in the world when I work with a nurse who works with me, has actually learned and can respect other approaches, but knows when to double check on an order,

Worst thing in the world is when you get a nurse who knows it all, and has gotten that knowledge by doing the same exact thing, day after day.  
Best of luck my friend!

[LT_Oneal_PAC]

4 hours ago, MediMike said:

I had a complaint filed after cranking Vaso up to 0.06 in a crashing pHTN guy to spare norepi. Pharmacist straight said to the nurse that it induced cardiac arrest at that dose.

So yeah, I've run into some barriers and the ED seems more set in their ways from a nursing standpoint. To be honest, I get more pushback from ED RNs about things than I do the ICU nurses.

What you're dealing with though sounds pretty over the damn top. My advice, if you want to make it work, step up as a leader in the department and "treat" their anxiety. Offer a sit down with the nursing leadership, offer a weekly chalk talk on some of the things you've pissed them off about.

With that being said though, sounds like it's an organizational issue as well. FP docs are distancing themselves as well. Got to be frustrating man, I'm sorry.

In residency, I almost never got push back from the ED nurses. Sometimes I did from the ICU nurses, but they didn’t know me other than I was just another off service resident and they were upfront with their questions and what they didn’t know. I’ve offered to present some lectures, but the med staff thought it would just be over there heads, as per my above post.

there are some organizational issues. The head Doc here is a true general practitioner who does it all, and really trusts the PAs letting us do whatever we are trained to do. He’s always happy when I want to submit a new policy to update what they are doing. But he also lives in this small town and doesn’t seem to like to push others buttons when it comes down to it. Some others are more wishy washy, saying “my license too”. Not exactly how it was presented in my interview, but wouldn’t be so bad if they didn’t submit to admin so much.

[Lightspeed]

You probably know this, but the problem isn’t the nurses as much as the fact that you have a collaborating physician.... a boss. Here is always someone for them to run to, so they will. The nurses where I am wouldn’t give you any trouble. But a toxic crew like where you are is surely going to mess with you for sport.

The other reason why your bigger brothers on the medical side aren’t taking your side (face it, it’s lip service.... if they really wanted that to end, it would be ended by now), is that..... they are your collaborating physicians.... your bosses. Their backside is on the line. They want little tattlers to check with them. It’s the nature of every physician to not want to be exposed to liability. They are willing to let your feelings get hurt to have one more speed bump between them and a subpoena. They ARE NOT going to give you cart blanche by telling the nurses to back the F off. Understand that, and everything else will become clear. 

I don’t have problems like this as an independent NP, because there is nobody for a nurse to complain to that will listen to them, except if you count maybe the medical director (who is obliged to listen). But there’s nobody that needs to.... or wants to.... step in to meddle. Anyone complaining to one of the other providers gets ignored. If a nurse were to ask a another provider to step in, that provider would give them a blank look and think to himself/herself “I’m not stepping into this”. They aren’t connected in any way. Nothing compels it. And as consequence, NPs here get treated with respect.... unless policy at the workplace dictates that a physicians name also turn up on the charts.... and then its open season, just like you. I used to do that to NPs myself when I didn’t agree with them. Make the call to the doc and get a second opinion. 

Being treated like that has to be jarring. It’s up to you to decide if you are going to command their respect, or earn it. You may feel like you’ve earned it, but as long as disdain is present, you won’t have earned anything. They will outlast you. If they don’t, then it will be because you spent an inordinate amount of time fixated on their lack of respect for you. And if they go, the legend of you being the villain will remain in the folks that stayed. And they will continue to screw you over. You know this, since you were a nurse once. 

I’m sure you have better things to worry about at any given moment than fighting that war. Any concessions that you win without using gentle persuasion will be served to you begrudgingly, further humiliating you in the process. 

What I learned from my rotations with physicians is that as residents and new providers, they didn’t have time to care much about that kind of pettiness on the part of nurses. They are the big dog, they know it. It isn’t until they are seasoned providers that you’ll see physicians start to wield power, and the smart ones do it gingerly. Trying to wield influence and falling on your face, like what you are doing, sets you back farther than not doing it at all. 

I’d suggest keeping your powder dry, don’t whine to admin. Continue to be a great provider in the face of that. They will look small. You’ll continue to feel overwhelming frustration, but think of it as an investment in your reputation. I know this sounds like not standing up for yourself, but I’ve never seen anyone win in that kind of environment by doing what you are doing. I’ve seen plenty of people win by encouraging buy-in. You might insist otherwise, but I’m certain you barge in a bit and do things your way when you could bend a little and gain friends. You have the alpha thing going on. You’ve been the ICU nurse, did the residency, are doing the military thing as an officer. I guess if you define victory by getting things exactly your way, while having them undermine you behind your back, then your current pathway will get you there. 

How I handle things like that is similar to how I handle my patients. I can prescribe them whatever I want to, and it doesn’t matter unless they take the med. they won’t take the med unless I spend the energy explaining things to them, but most of all, listening to them. They know when I’m faking. There’s always time to teach. Think out loud. Ask them what they would do, and when you don’t do it that way, explain it. Make it the exception rather than the rule for you to blow past them because there isn’t enough time for you to “waste” by having a two way conversation. 

[LT_Oneal_PAC]

2 hours ago, Lightspeed said:

You probably know this, but the problem isn’t the nurses as much as the fact that you have a collaborating physician.... a boss. Here is always someone for them to run to, so they will. The nurses where I am wouldn’t give you any trouble. But a toxic crew like where you are is surely going to mess with you for sport.

The other reason why your bigger brothers on the medical side aren’t taking your side (face it, it’s lip service.... if they really wanted that to end, it would be ended by now), is that..... they are your collaborating physicians.... your bosses. Their backside is on the line. They want little tattlers to check with them. It’s the nature of every physician to not want to be exposed to liability. They are willing to let your feelings get hurt to have one more speed bump between them and a subpoena. They ARE NOT going to give you cart blanche by telling the nurses to back the F off. Understand that, and everything else will become clear. 

I don’t have problems like this as an independent NP, because there is nobody for a nurse to complain to that will listen to them, except if you count maybe the medical director (who is obliged to listen). But there’s nobody that needs to.... or wants to.... step in to meddle. Anyone complaining to one of the other providers gets ignored. If a nurse were to ask a another provider to step in, that provider would give them a blank look and think to himself/herself “I’m not stepping into this”. They aren’t connected in any way. Nothing compels it. And as consequence, NPs here get treated with respect.... unless policy at the workplace dictates that a physicians name also turn up on the charts.... and then its open season, just like you. I used to do that to NPs myself when I didn’t agree with them. Make the call to the doc and get a second opinion. 

Being treated like that has to be jarring. It’s up to you to decide if you are going to command their respect, or earn it. You may feel like you’ve earned it, but as long as disdain is present, you won’t have earned anything. They will outlast you. If they don’t, then it will be because you spent an inordinate amount of time fixated on their lack of respect for you. And if they go, the legend of you being the villain will remain in the folks that stayed. And they will continue to screw you over. You know this, since you were a nurse once. 

I’m sure you have better things to worry about at any given moment than fighting that war. Any concessions that you win without using gentle persuasion will be served to you begrudgingly, further humiliating you in the process. 

What I learned from my rotations with physicians is that as residents and new providers, they didn’t have time to care much about that kind of pettiness on the part of nurses. They are the big dog, they know it. It isn’t until they are seasoned providers that you’ll see physicians start to wield power, and the smart ones do it gingerly. Trying to wield influence and falling on your face, like what you are doing, sets you back farther than not doing it at all. 

I’d suggest keeping your powder dry, don’t whine to admin. Continue to be a great provider in the face of that. They will look small. You’ll continue to feel overwhelming frustration, but think of it as an investment in your reputation. I know this sounds like not standing up for yourself, but I’ve never seen anyone win in that kind of environment by doing what you are doing. I’ve seen plenty of people win by encouraging buy-in. You might insist otherwise, but I’m certain you barge in a bit and do things your way when you could bend a little and gain friends. You have the alpha thing going on. You’ve been the ICU nurse, did the residency, are doing the military thing as an officer. I guess if you define victory by getting things exactly your way, while having them undermine you behind your back, then your current pathway will get you there. 

How I handle things like that is similar to how I handle my patients. I can prescribe them whatever I want to, and it doesn’t matter unless they take the med. they won’t take the med unless I spend the energy explaining things to them, but most of all, listening to them. They know when I’m faking. There’s always time to teach. Think out loud. Ask them what they would do, and when you don’t do it that way, explain it. Make it the exception rather than the rule for you to blow past them because there isn’t enough time for you to “waste” by having a two way conversation. 

I disagree. The problem is small minded people and the nursing mindset of “protecting my license,” which usually equates to “change is risky, thus change threatens my license.” I don’t think the nurses here are toxic. They are good nurses and I trust their opinions, but they’ve only seen a narrow sliver of practice because they’ve never had someone who was actually trained in EM, so now they are outside their comfort zone.

Its not jarring. I don’t expect to list my resume and command respect. That comes with time and observation. What is frustrating is people not wanting to do what is right for the patient because of fear. I’m not trying to wield influence, I’m just practicing good medicine.

I have not gotten any impression from the med staff they want me on a leash. Some want to be called about certain things, but they have were upfront that it was about their own insecurities.

i haven’t said one word to admin. They haven’t spoken with me either. I do not whine. You’re right, I will counter and say I don’t barge. I command the situation in an emergency, a skill that is necessary in a emergent situation and I don’t expect a person who hasn’t done an EM rotation to understand. But outside of that I’ve never denied a nursing request, not answered a question, or not addressed a concern when it was brought to me. I’m very flexible to the requests and concerns of nurses, but I won’t “bend” when it comes to providing the highest standard of care. That means I’m going to do that US for a DVT when I can’t get formal US at night instead of potentially heparinizing a patient unnecessarily until I can. I’m going to do an US guided IV after they failed 4 times to get one and not let them make a pin cushion out of patient. If they had a concern, they could have brought it to me and not go to the DON.

I define victory as doing what is best for the patient and everyone being on board that the patient comes first. Mission first, individual second.

as far as your approach, I’ve explained that I’m willing to teach. To take your metaphor, it’s like your patient saying okay then going to your CEO, without full knowledge of what is best for them and speaking to a person who has no authority or training to dictate good medical practice, and saying your are inappropriately prescribing meds.

thanks for trying to help, but for future people who see your post, you’re off base.

[PickleRick]

Have to call bull#%*^ on Lightspeed's response.  This has ZERO to do with physician supervision or collaboration.  I have read a number of your responses on this forum and, your veiled attempts at getting in a rub on the PA profession do not go unnoticed. At least not by me.

[Lightspeed]

2 hours ago, PickleRick said:

Have to call bull#%*^ on Lightspeed's response.  This has ZERO to do with physician supervision or collaboration.  I have read a number of your responses on this forum and, your veiled attempts at getting in a rub on the PA profession do not go unnoticed. At least not by me.

It’s pointing out the obvious. I do a good job of including an explanation with my response as well. All you just did is say that you don’t agree.

Tell me this.... if a given patient was his, and his alone, what kind of grief would he be experiencing from those nurses over this right now? None. He’d tell them to pound sand. That would be that. To say it has “zero to do with physician supervision or collaboration” is laughable. It would be generous for me to cede any ground of that, but even under generous circumstances, the collaboration aspect of the problem would be at least 95% of the problem at hand.  

Most of your profession’s frustrations come back to independence and a few other related issues. It’s not your profession, it belongs to physicians. This point should be driven home every time the conversation heads to that obvious conclusion. 

As for some of the other issues I touched upon, I stand by my responses as well. The approach I espouse is true whether you are a PA, NP, or physician. If someone tries to pull any kind of rank in that environment as part of a battle of wills, you get a bittersweet prize. If one shows that you are a team player, one gets farther. Your mileage may vary. Call bul#%*^ on that all you want. 

Edited September 29, 2019 by Lightspeed

[Marinejiujitsu]

So, I’ve been at my CAH EM/Hospitalist job for over a month now. In that time, I’ve had the nurses send 4 emails about “concerns” and last night they called my admin supervisor who texted my back up physician. Not a single bad outcome or “near miss,” they are just freaking out when I do typical EM things. They sent an email about me using push dose pressors and upset that I pushed the drug, not them (I did because they had never done it or knew how to mix it up). Sent another email because I used pain dose ketamine (0.1mg/kg). To be fair I did not realize they didn’t have a policy for this and I have since written a policy for them. Last night they were all pissy because I used an US to reassure a patient didn’t have a DVT with very low suspicion, that I did US guided IVs, and used it emergently to rule out pneumothorax. They question everything damn thing I do. My CP this morning chatted with me and agreed they are questioning to an inappropriate level. I would address their concerns, but they don’t come to me with questions. Instead go over my head immediately. My CP thinks the solution is to call the back up to talk about the things I’m doing and alleviate the fears of nursing that the docs have blessed my actions, which I think is dumb since I’m not there to treat patients and not nurses anxiety, and frankly a waste of my time. I was an ICU nurse for 4 years, and I don’t get their concerns because there is no evidence of deviation from the standard of care. No data for an incident report either. It reminds of when I started as a nurse and people just didn’t like doing things other than how they were always done. A nurse gave me a dirty look today because I said I wouldn’t be a middle man between the sheriff office and the ME. Sheriff office calls me, I’m supposed to call ME that office knows the number for, and then the ME calls sheriff office. I add nothing to the interaction other than a glorified switchboard operator. Honestly, I’m thinking about leaving since the FM docs aren’t really crazy about doing US for anything other than FAST, and they aren’t super jazzed about learning that. I presented them with everything they needed to build up an US program and bill for it, but they took it off the med staff agenda saying it wasn’t approved by the CEO to be added.
for reference, apparently up until a year ago only providers could push fentanyl.
maybe this is just venting. Anyone have a similar situation. 

That's the problem working at places with just FPs running ther place. Nursing staff doesn't understand when actual emergency trained providers try to do basic things.

Sent from my SM-N975U using Tapatalk

[Lightspeed]

3 hours ago, LT_Oneal_PAC said:

I disagree. The problem is small minded people and the nursing mindset of “protecting my license,” which usually equates to “change is risky, thus change threatens my license.” I don’t think the nurses here are toxic. They are good nurses and I trust their opinions, but they’ve only seen a narrow sliver of practice because they’ve never had someone who was actually trained in EM, so now they are outside their comfort zone.

Its not jarring. I don’t expect to list my resume and command respect. That comes with time and observation. What is frustrating is people not wanting to do what is right for the patient because of fear. I’m not trying to wield influence, I’m just practicing good medicine.

I have not gotten any impression from the med staff they want me on a leash. Some want to be called about certain things, but they have were upfront that it was about their own insecurities.

i haven’t said one word to admin. They haven’t spoken with me either. I do not whine. You’re right, I will counter and say I don’t barge. I command the situation in an emergency, a skill that is necessary in a emergent situation and I don’t expect a person who hasn’t done an EM rotation to understand. But outside of that I’ve never denied a nursing request, not answered a question, or not addressed a concern when it was brought to me. I’m very flexible to the requests and concerns of nurses, but I won’t “bend” when it comes to providing the highest standard of care. That means I’m going to do that US for a DVT when I can’t get formal US at night instead of potentially heparinizing a patient unnecessarily until I can. I’m going to do an US guided IV after they failed 4 times to get one and not let them make a pin cushion out of patient. If they had a concern, they could have brought it to me and not go to the DON.

I define victory as doing what is best for the patient and everyone being on board that the patient comes first. Mission first, individual second.

as far as your approach, I’ve explained that I’m willing to teach. To take your metaphor, it’s like your patient saying okay then going to your CEO, without full knowledge of what is best for them and speaking to a person who has no authority or training to dictate good medical practice, and saying your are inappropriately prescribing meds.

thanks for trying to help, but for future people who see your post, you’re off base.

You responded exactly how I expected you would.  

I do appreciate the value of having a command presence as a provider, despite not working in an ER role. I live it too. What you said was a dig dished out as an attempt to save face, but it highlights your tunnel vision. Relax and accept that the world outside of ER also contains high stakes, the potential for tense interactions, and the need for resolute actions. 

If you are expecting anyone to sacrifice their attitude of “protecting their license” to satisfy the new approach you wish to bring to them, you are asking a lot from the parties involved. They certainly won’t follow you into that expanse, which is why you are seeing lack of respect from the “small minded nurses”, and seeing a lack of resolute support from your superiors, which is something that you seem to be in denial of. At the very least, they might be tepidly supporting you while they model the patient approach that you lack. 

So I’ve seen this all before, and actually not with PAs, but with NPs who probably had less to boast about than you as far as clinical skill. It all comes down to what you want to spend your currency on. You are going to take the alpha approach of “mission first, but my way”, and you’ll continue to be undermined. I’ve even seen well qualified physicians fail in that exact environment, with that exact approach. So while this issue heavily lopsided towards being a problem of supervision, it could clearly also be one of expectations exceeding authority. 

Edited September 29, 2019 by Lightspeed

[LT_Oneal_PAC]

3 hours ago, Lightspeed said:

You responded exactly how I expected you would.  

I do appreciate the value of having a command presence as a provider, despite not working in an ER role. I live it too. What you said was a dig dished out as an attempt to save face, but it highlights your tunnel vision. Relax and accept that the world outside of ER also contains high stakes, the potential for tense interactions, and the need for resolute actions. 

If you are expecting anyone to sacrifice their attitude of “protecting their license” to satisfy the new approach you wish to bring to them, you are asking a lot from the parties involved. They certainly won’t follow you into that expanse, which is why you are seeing lack of respect from the “small minded nurses”, and seeing a lack of resolute support from your superiors, which is something that you seem to be in denial of. At the very least, they might be tepidly supporting you while they model the patient approach that you lack. 

So I’ve seen this all before, and actually not with PAs, but with NPs who probably had less to boast about than you as far as clinical skill. It all comes down to what you want to spend your currency on. You are going to take the alpha approach of “mission first, but my way”, and you’ll continue to be undermined. I’ve even seen well qualified physicians fail in that exact environment, with that exact approach. So while this issue heavily lopsided towards being a problem of supervision, it could clearly also be one of expectations exceeding authority. 

You expected me to disagree? You must be a brilliant psych provider. How could one be so clairvoyant? I need to save no face. As far as putting patient (mission) first, I’m not going to apologize for that. If you point is that I should be willing to deviate from best medical practice, then your right. I’m stubborn and will not abide. Also know that not using ultrasound at all is a lesser level of care. Present to me a way I can rule out a pneumothorax in seconds with 98% sensitivity, or even evidence that patients are equally satisfied  being poked 10 times vs once using ultrasound, and I’ll accept your position that 

As far as the CP thing, I would say it was about them if the nurses were going to the CP, but they are going to the DON, someone who is not in anyway my boss or a clinical authority.

I’m not sure what your it getting. I’m not asking the nurses to do anything at all other than let me do my job. Do you think I would be in the wrong if they didn’t bend when if I politely asked  a nurse to use sterile gloves on every IV insertion? Or more apt analogy, to not use gloves at all? If I may psychoanalyze you, you have a obsession with always being right. You can not lose an intellectual debate in your mind, but you don’t see it as subjective. No, you pretend that you see all the trains of thought going through a persons mind and how it would be better if they thought like you. “If only people thought like me, this world would be a better place.” This is particular notable how you constantly bring up in multiple threads about the CP issue. You just can’t let it go that we don’t totally, 100%, unanimously agree with you. The funny thing is I mostly agree with you on those topics, but your so abrasive, I can’t even bring myself to post it on those threads. So, like an obsessive compulsive, you come back time and again to find a thread where you can bring it up again, as nauseum.

Dont answer. Please stop detailing my thread. You’ve made your point that you think I’m the problem or if I did it your way it would all vanish, though I’ve proven that I’m willing to talk out an issue and not just blow even you off. I’m sure you’ll return with, “but your shutting me down, not wanting me to speak, just like I thought Mr. Bond.” I just don’t want to keep dancing in circles all day on an issue that ultimately doesn’t matter. 

 

[CAdamsPAC]

20 hours ago, LT_Oneal_PAC said:

So, I’ve been at my CAH EM/Hospitalist job for over a month now. In that time, I’ve had the nurses send 4 emails about “concerns” and last night they called my admin supervisor who texted my back up physician. Not a single bad outcome or “near miss,” they are just freaking out when I do typical EM things. They sent an email about me using push dose pressors and upset that I pushed the drug, not them (I did because they had never done it or knew how to mix it up). Sent another email because I used pain dose ketamine (0.1mg/kg). To be fair I did not realize they didn’t have a policy for this and I have since written a policy for them. Last night they were all pissy because I used an US to reassure a patient didn’t have a DVT with very low suspicion, that I did US guided IVs, and used it emergently to rule out pneumothorax. They question everything damn thing I do. My CP this morning chatted with me and agreed they are questioning to an inappropriate level. I would address their concerns, but they don’t come to me with questions. Instead go over my head immediately. My CP thinks the solution is to call the back up to talk about the things I’m doing and alleviate the fears of nursing that the docs have blessed my actions, which I think is dumb since I’m not there to treat patients and not nurses anxiety, and frankly a waste of my time. I was an ICU nurse for 4 years, and I don’t get their concerns because there is no evidence of deviation from the standard of care. No data for an incident report either. It reminds of when I started as a nurse and people just didn’t like doing things other than how they were always done. A nurse gave me a dirty look today because I said I wouldn’t be a middle man between the sheriff office and the ME. Sheriff office calls me, I’m supposed to call ME that office knows the number for, and then the ME calls sheriff office. I add nothing to the interaction other than a glorified switchboard operator. Honestly, I’m thinking about leaving since the FM docs aren’t really crazy about doing US for anything other than FAST, and they aren’t super jazzed about learning that. I presented them with everything they needed to build up an US program and bill for it, but they took it off the med staff agenda saying it wasn’t approved by the CEO to be added.

for reference, apparently up until a year ago only providers could push fentanyl.

maybe this is just venting. Anyone have a similar situation. 

Typical backstabbing behaviors from ignorant insecure nurses who are jealous of your ability to getting  things done without their input or CONTROL !! You've done nothing wrong and now you are being asked to pander to their insecurities!! I think your true supervisor needs to pass the word back down the ranks that you don't answer to them, and unless the PHYSICIANS have a concern with your PRACTICING MEDICINE they should shut up and stop their ignorant whining!!!!

[CAdamsPAC]

3 hours ago, Lightspeed said:

It’s pointing out the obvious. I do a good job of including an explanation with my response as well. All you just did is say that you don’t agree.

Tell me this.... if a given patient was his, and his alone, what kind of grief would he be experiencing from those nurses over this right now? None. He’d tell them to pound sand. That would be that. To say it has “zero to do with physician supervision or collaboration” is laughable. It would be generous for me to cede any ground of that, but even under generous circumstances, the collaboration aspect of the problem would be at least 95% of the problem at hand.  

Most of your profession’s frustrations come back to independence and a few other related issues. It’s not your profession, it belongs to physicians. This point should be driven home every time the conversation heads to that obvious conclusion. 

As for some of the other issues I touched upon, I stand by my responses as well. The approach I espouse is true whether you are a PA, NP, or physician. If someone tries to pull any kind of rank in that environment as part of a battle of wills, you get a bittersweet prize. If one shows that you are a team player, one gets farther. Your mileage may vary. Call bul#%*^ on that all you want. 

Okay PAs don't practice independently. You've told us in various iterations, something not news to us. Now go away if that's your one trick pony on this forum.

[GetMeOuttaThisMess]

As noted previously, many are content to just stick with what they know, draw the paycheck, and the patient be damned. “There’s an order for a gastric lavage? OK, we’ve done those before. This tube sure looks larger but hey, it’s a gastric lavage and I didn’t need to attend the inservice.” A few minutes later, “GMOTM, I have a patient that’s bleeding really bad from the nose.” You go back to look, patient is bleeding like a stuck pig, and they don’t understand why the Ewald won’t go down the nostrils. True story. When did medicine become a process of covering your ass first instead of helping the patient? Maybe I can work this out in my psych counseling in retirement from a provider that wouldn’t know an NG tube from an Ewald if it bit them where the sun doesn’t shine.

 

Unless you’ve been on the front line in the ED seeing more than just fast track patients then you don’t have skins in the game.

 

 

 

[Lightspeed]

1 hour ago, LT_Oneal_PAC said:

You expected me to disagree? You must be a brilliant psych provider. How could one be so clairvoyant? I need to save no face. As far as putting patient (mission) first, I’m not going to apologize for that. If you point is that I should be willing to deviate from best medical practice, then your right. I’m stubborn and will not abide. Also know that not using ultrasound at all is a lesser level of care. Present to me a way I can rule out a pneumothorax in seconds with 98% sensitivity, or even evidence that patients are equally satisfied  being poked 10 times vs once using ultrasound, and I’ll accept your position that 

As far as the CP thing, I would say it was about them if the nurses were going to the CP, but they are going to the DON, someone who is not in anyway my boss or a clinical authority.

I’m not sure what your it getting. I’m not asking the nurses to do anything at all other than let me do my job. Do you think I would be in the wrong if they didn’t bend when if I politely asked  a nurse to use sterile gloves on every IV insertion? Or more apt analogy, to not use gloves at all? If I may psychoanalyze you, you have a obsession with always being right. You can not lose an intellectual debate in your mind, but you don’t see it as subjective. No, you pretend that you see all the trains of thought going through a persons mind and how it would be better if they thought like you. “If only people thought like me, this world would be a better place.” This is particular notable how you constantly bring up in multiple threads about the CP issue. You just can’t let it go that we don’t totally, 100%, unanimously agree with you. The funny thing is I mostly agree with you on those topics, but your so abrasive, I can’t even bring myself to post it on those threads. So, like an obsessive compulsive, you come back time and again to find a thread where you can bring it up again, as nauseum.

Dont answer. Please stop detailing my thread. You’ve made your point that you think I’m the problem or if I did it your way it would all vanish, though I’ve proven that I’m willing to talk out an issue and not just blow even you off. I’m sure you’ll return with, “but your shutting me down, not wanting me to speak, just like I thought Mr. Bond.” I just don’t want to keep dancing in circles all day on an issue that ultimately doesn’t matter. 

 

I don’t need to drive my point home, you are making it yourself. Everyone around you is the problem. Your technical skills will insulate you. None of the problem people can grasp the excellence of your approach, all of them are the issue. The FM folks like to go slow (but the people that are awesome “get” you). 

Those nurses are going through their chain of command, and maybe skipping a few steps with regard to their own organizational structure, but that’s on them. They don’t owe it to you to bring it to you, or bring it to any other physician. You know that’s true.

I didn’t make the connection before, but it’s the nurse in you that’s causing the problem, hence the reason I don’t see many PAs getting that kind of flack vs the NPs I’ve seen that came into their work environment with super-nurse “let me blaze my own trail” MASH 4077 tendencies. Those nurses around you probably resent it. You seem to have some significant RN skills, and then took that passion to the PA field. Good on you. It’s going to chaff some folks. They will try to eat you as one of the rogue young that left the fold. No biggie, you are a different species now. They skip going to the CP, but because you have a CP they feel entitled to complain about you. Just that format of supervision unfortunately promotes the attitude of undermining.

How myself and all the team players of the world handle things is I’d walk in and in friendly terms in the middle of requests I’d address the elephant in the room. “Hey, so I know I do things a bit different, but the reason I’m doing X right now is because that’s how I’ve trained to do this. Do you have any suggestions or reservations to that, because maybe there is something I’m missing, and if there is I’m always here to learn to do things better. Doesn’t mean I will agree, but we can definitely look at the big issue here.”

Can’t always do that in the middle of a crisis, but the same theme applies later on in the recap. Make time for it, and it won’t make it up the chain. If it does, then you showed due diligence and can cite it. You are then a stud for trying to fix it on your own. It’s worth noting. With that being what it is, though, the change comes from you fixing it yourself. Instead of “thinking it’s dumb because you are there to treat patients and not anxious nurses” and seeing it as a “waste of time”, engage with them like you bosses are modeling to you to do. They are literally telling you with their actions that they don’t agree with your approach. When you don’t model that back to them, you are not only letting the nurses know you think they are off the mark, you are also telling your CP and any medical staff involved that you feel the same about them. The nurses will react with more adolescent behaviors than the physicians, most likely, but the physicians will tend to react just like they have. 

You just aren’t steering into the turn. I could speculate it’s because of the super nurse in you, or the super PA in you, and maybe that’s not fair, but you gave a very brief amount of time to my pushback before you went nuclear, so maybe that’s part of it? I don’t know. But why ask the question just to fly off the handle. Mostly in those situations it’s not the environment against you. Too many people have to coordinate to make that happen.  

 

1 hour ago, CAdamsPAC said:

Okay PAs don't practice independently. You've told us in various iterations, something not news to us. Now go away if that's your one trick pony on this forum.

That was one thing that was touched upon. There were other points made as well. Wouldn’t the obsessions on here about NPs also fall into the category of being a one trick topic? 

If you are implying I’m a troll, get on with it. I think that would indict a lot of other folks on here who have a single minded obsession. 

Edited September 29, 2019 by Lightspeed

[LT_Oneal_PAC]

1 hour ago, Lightspeed said:

I don’t need to drive my point home, you are making it yourself. Everyone around you is the problem. Your technical skills will insulate you. None of the problem people can grasp the excellence of your approach, all of them are the issue. The FM folks like to go slow (but the people that are awesome “get” you). 

Those nurses are going through their chain of command, and maybe skipping a few steps with regard to their own organizational structure, but that’s on them. They don’t owe it to you to bring it to you, or bring it to any other physician. You know that’s true.

I didn’t make the connection before, but it’s the nurse in you that’s causing the problem, hence the reason I don’t see many PAs getting that kind of flack vs the NPs I’ve seen that came into their work environment with super-nurse “let me blaze my own trail” MASH 4077 tendencies. Those nurses probably resent it. You seem to have some significant RN skills, and then took that passion to the PA field. Good on you. It’s going to chaff some folks. They will try to eat you as one of the rogue young that led the fold. No biggie, you are a different species now. They skip going to the CP, but because you have a CP they feel entitled to complain about you. Just that format of supervision unfortunately promotes the attitude of undermining.

How myself and all the team players of the world handle things is I’d walk in and in friendly terms in the middle of requests I’d address the elephant in the room. “Hey, so I know I do things a bit different, but the reason I’m doing X right now is because that’s how I’ve trained to do this. Do you have any suggestions or reservations to that, because maybe there is something I’m missing, and if there is I’m always here to learn to do things better. Doesn’t mean I will agree, but we can definitely look at the big issue here.” Can’t always do that in the middle of a crisis, but the same theme applies later on in the recap. Make time for it, and it won’t make it up the chain. If it does, then you showed due diligence and can cite it. You are then a stud for trying to fix it on your own. It’s worth noting. With that being what it is, though, the change comes from you fixing it yourself. 

You just aren’t steering into the turn. I could speculate it’s because of the super nurse in you, or the super PA in you, and maybe that’s not fair, but you gave a very brief amount of time to my pushback before you went nuclear, so maybe that’s part of it? I don’t know. But why ask the question just to fly off the handle. Mostly in those situations it’s not the environment against you. Too many people have to coordinate to make that happen.  

 

That was one thing that was touched upon. There were other points made as well. Wouldn’t the obsessions on here about NPs also fall into the category of being a one trick topic? 

If you are implying I’m a troll, get on with it. I think that would indict a lot of other folks on here who have a single minded obsession. 

Sigh. Not everyone is the problem. The med staff isn’t. Not all the nurses are. I always ask this question at the beginning of any conflict as I’ve seen that play out before too. No I don’t appreciate people going past me instead Of bringing issues to me first. I’ve done the exact thing you quoted above when requests are brought to me, asking for input, but I can’t do that when they aren’t asking me questions. I certainly cannot do it for every single decision. Then it would just be internal medicine rounds where we are all mentally masturbating on one patient for 2 hours.

No one went nuclear. If I wanted to go nuclear or save face, I would just hide your posts or ban you. I don’t know who invalidated your thoughts and feelings as a child to the point you must have everyone as adult make you feel as though your heard, but I’m sorry. Continue talking if this is your therapy.

I said good day, sir. I won’t be responding again to you. Obviously you have to have things your way and are inflexible. 

[CAdamsPAC]

1 hour ago, Lightspeed said:

I don’t need to drive my point home, you are making it yourself. Everyone around you is the problem. Your technical skills will insulate you. None of the problem people can grasp the excellence of your approach, all of them are the issue. The FM folks like to go slow (but the people that are awesome “get” you). 

Those nurses are going through their chain of command, and maybe skipping a few steps with regard to their own organizational structure, but that’s on them. They don’t owe it to you to bring it to you, or bring it to any other physician. You know that’s true.

I didn’t make the connection before, but it’s the nurse in you that’s causing the problem, hence the reason I don’t see many PAs getting that kind of flack vs the NPs I’ve seen that came into their work environment with super-nurse “let me blaze my own trail” MASH 4077 tendencies. Those nurses around you probably resent it. You seem to have some significant RN skills, and then took that passion to the PA field. Good on you. It’s going to chaff some folks. They will try to eat you as one of the rogue young that left the fold. No biggie, you are a different species now. They skip going to the CP, but because you have a CP they feel entitled to complain about you. Just that format of supervision unfortunately promotes the attitude of undermining.

How myself and all the team players of the world handle things is I’d walk in and in friendly terms in the middle of requests I’d address the elephant in the room. “Hey, so I know I do things a bit different, but the reason I’m doing X right now is because that’s how I’ve trained to do this. Do you have any suggestions or reservations to that, because maybe there is something I’m missing, and if there is I’m always here to learn to do things better. Doesn’t mean I will agree, but we can definitely look at the big issue here.”

Can’t always do that in the middle of a crisis, but the same theme applies later on in the recap. Make time for it, and it won’t make it up the chain. If it does, then you showed due diligence and can cite it. You are then a stud for trying to fix it on your own. It’s worth noting. With that being what it is, though, the change comes from you fixing it yourself. Instead of “thinking it’s dumb because you are there to treat patients and not anxious nurses” and seeing it as a “waste of time”, engage with them like you bosses are modeling to you to do. They are literally telling you with their actions that they don’t agree with your approach. When you don’t model that back to them, you are not only letting the nurses know you think they are off the mark, you are also telling your CP and any medical staff involved that you feel the same about them. The nurses will react with more adolescent behaviors than the physicians, most likely, but the physicians will tend to react just like they have. 

You just aren’t steering into the turn. I could speculate it’s because of the super nurse in you, or the super PA in you, and maybe that’s not fair, but you gave a very brief amount of time to my pushback before you went nuclear, so maybe that’s part of it? I don’t know. But why ask the question just to fly off the handle. Mostly in those situations it’s not the environment against you. Too many people have to coordinate to make that happen.  

 

That was one thing that was touched upon. There were other points made as well. Wouldn’t the obsessions on here about NPs also fall into the category of being a one trick topic? 

If you are implying I’m a troll, get on with it. I think that would indict a lot of other folks on here who have a single minded obsession. 

Your fixation with PAs lacking independent practice seems to constantly manifest  itself in your posts. I could refer to the sun rising each day which is a well known undisputed fact, which wouldn't add to the general discussion on PAF.  Like LT_ONEAL_PAC I will now move you to my ignore file.

[Cideous]

Assistant....

[Boatswain2PA]

On 9/28/2019 at 5:06 PM, LT_Oneal_PAC said:

So, I’ve been at my CAH EM/Hospitalist job for over a month now.....

Your problems have nothing to do with supervision requirements (Yeah, Lightspeed -- you're like a broken record...that's usually WRONG).

It's the nurses, and the nursing management who doesn't balance the discomfort of the nursing staff to changes with the need to practice evidence based medicine.

I've been there, working in a very rural place with absolutely incompetent toxic nurses who I would have to search for (and find outside smoking) to get me medicine from the pixis to care for acutely ill patients, and then deal with the nurse complaints later.

I also work at a busy/high acuity shop now with absolutely TREMENDOUS nurses who, without exception, complain about a NP because of their incompetence.  And, to utterly refute lightspeeds rant about this being all about PAs being dependent providers, none of the nurses at this shop will take an order from this NP...and this is in an "NP independent" state. 

LT - If you've tried to educate the nurses and they are intransigent, then I would start looking for another place.  

Good luck!

 

[LT_Oneal_PAC]

3 minutes ago, Lightspeed said:

Ok. So I guess the quotes from you about feeling like it’s a waste of time to deal with nurses on the subject, and that your job isn’t to treat their anxiety by addressing their concerns is just something to walk back. I get it. It’s your way. It’s not you that is trying to “be heard”. I guess it’s me that ruined your thread. Hey, thanks for not deleting my posts. 

 

If it comes up, it comes up. It touches upon so many aspects of practice that if it doesn’t show up, it’s being ignored. But another subject that seems as constant as the rising sun... dissatisfaction of how good NPs have it that there is constant chatter about things like NP educational standards, clinical rotations, inferiority, nursing lobby punching above their weight, the overall unfairness of it all. Can’t really deny it because it always comes up. Even when I’ve suggested it should be times down because it’s polluting your discourse with a 1984 style 2 minutes of hate, the ire towards NPs has got to come up as a feature. 

God help me, I just can’t stop. I just can’t abide now a blatant lack of reading comprehension. I never said alleviating their fears is a waste of my time. I’be offered to do that through teaching. I said calling the back up physician for whatever nursing concern is that day is a waste of my time. If I know the answer and the evidence behind it, asking someone to to confirm is redundant. If the nurses have concerns and don’t like my explanation, they can call.

okay done. I’m also putting you in the ignore list to quit you cold turkey.

[CookiePA]

"1. They sent an email about me using push dose pressors and upset that I pushed the drug, not them (I did because they had never done it or knew how to mix it up). 2. Sent another email because I used pain dose ketamine (0.1mg/kg). To be fair I did not realize they didn’t have a policy for this and I have since written a policy for them. 3. Last night they were all pissy because I used an US to reassure a patient didn’t have a DVT with very low suspicion, that I did US guided IVs, and used it emergently to rule out pneumothorax. 4. They question everything damn thing I do. My CP this morning chatted with me and agreed they are questioning to an inappropriate level."

1. You are a provider who is well trained to do much more and push a drug if needed. Nurses can pull the drug and verify and you can verify the drug with them when in the room for documentation purposes. 

2. Again you did nothing other than EBM and corrected the facility issue by providing them with a policy. 

3. Again lack of competency that you shouldnt have to be responsible for. 

4. 100% inappropriate. Your practices are backed up by clinical practice and do not deviate from standard of care. You have done nothing wrong other than provide exceptional services to the patients. This is a nursing problem and lack of willingness to learn on their part. This is not your supervising physicians collaboration issue despite Lightspeed's attempt to tell us all how we are doomed because of our Physicians. 

You have offered to be a teacher and teach the nurses to reduce their anxiety and to hopefully make them your teammates who are competent and know why things are being done a certain way. "Data will go over their head" is not an excuse. Nurses are all about data and how to improve/streamline operations.  Why is this situation any different? This screams lack of willingness to learn because it is not coming from nursing leadership but from a provider, who just happens to be new to the block NOT new to medicine.

In all honestly it sounds like nurses are pissed off they are not running the show and are insecure. This is clearly reflected in their behavior of happy emailing and going over your head. That is inappropriate. If nursing leadership is THAT worried about patients and safety they can all surely teach a class or two.

Keep doing you and teach if/when you can when time allows. 

 

 

 

 

 

[Marinejiujitsu]

Whenever I have worked for a strike team or new rural place its always awful at first. Nurses not trusting your decisions but the more crap you pick up and they see your education/experience level they back off. I have told some of the nurses that I love, "you were a prick to me when I first started." They usually say, "I didn't know I was being like that." But you know very well at the time they did. Then they say usually the place doesn't get good providers, so they notice patterns of crappy non standard of care practices that they leach on to. Nurses will love you more the faster you get their patients out the door even they know sometimes they are wrong when they are pushing you to discharge. I don't know if its just laziness or incompetence. But i assume its laziness because they will discharge them, then leave the patient on the tracker for 2 hours so they don't get another patient.

Sent from my SM-N975U using Tapatalk

[Lightspeed]

I’ll walk back the intense snark I displayed in the interest of future comity, if possible. 

I’d echo what marinejujitsu suggested (which he put in a better way). There are ways to be a team player that put your opponents into the friend column. Yes, I have experienced that kind of loaded task. When frustration has reigned, I could trace it back to me every time. Either I was at fault with my approach or attitude, or else I was at fault because I didn’t take a vested interest in countering underserved criticism correctly. Either way, I lose when I’m not part of the solution. I don’t mean trying to find a solution, I mean succeeding at finding a solution. Points for trying are like field goals when you need touchdowns, especially in bosses eyes. And that’s made me a better person to have to negotiate through life than have expectations of how people will respect me. It’s on their terms, either I like it or not.